Milagros Abreu

Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters.

STUDY OBJECTIVE To compare interpreter errors and their potential consequences in encounters with professional versus ad hoc versus no interpreters. METHODS This was a cross-sectional error analysis of audiotaped emergency department (ED) visits during 30 months in the 2 largest pediatric EDs in Massachusetts. Participants were Spanish-speaking limited-English-proficient patients, caregivers, and their interpreters. Outcome measures included interpreter error numbers, types, and potential consequences. RESULTS The 57 encounters included 20 with professional interpreters, 27 with ad hoc interpreters, and 10 with no interpreters; 1,884 interpreter errors were noted, and 18% had potential clinical consequences. The proportion of errors of potential consequence was significantly lower for professional (12%) versus ad hoc (22%) versus no interpreters (20%). Among professional interpreters, previous hours of interpreter training, but not years of experience, were significantly associated with error numbers, types, and potential consequences. The median errors by professional interpreters with greater than or equal to 100 hours of training was significantly lower, at 12, versus 33 for those with fewer than 100 hours of training. Those with greater than or equal to 100 hours of training committed significantly lower proportions of errors of potential consequence overall (2% versus 12%) and in every error category. CONCLUSION Professional interpreters result in a significantly lower likelihood of errors of potential consequence than ad hoc and no interpreters. Among professional interpreters, hours of previous training, but not years of experience, are associated with error numbers, types, and consequences. These findings suggest that requiring at least 100 hours of training for interpreters might have a major impact on reducing interpreter errors and their consequences in health care while improving quality and patient safety.

Keeping Children With Asthma Out of Hospitals: Parents' and Physicians' Perspectives on How Pediatric Asthma Hospitalizations Can Be Prevented

Background. A total of 196000 hospitalizations occur each year among the 9 million US children who have been diagnosed with asthma. Not enough is known about how to prevent pediatric asthma hospitalizations. Objectives. To identify the proportion of preventable pediatric asthma hospitalizations and how such hospitalizations might be prevented, according to parents and physicians of hospitalized children with asthma. Methods. A cross-sectional survey was conducted of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of all children who were admitted for asthma to an urban hospital in a 14-month period. Results. The 230 hospitalized children had a median age of 5 years; most were poor (median annual family income:

A Randomized, Controlled Trial of the Effectiveness of Community-Based Case Management in Insuring Uninsured Latino Children

13356), were nonwhite (93%), and had public (74%) or no (14%) health insurance. Compared with children who were hospitalized for other ambulatory care–sensitive conditions, hospitalized children with asthma were significantly more likely to be African American (70% vs 57%), to be older, and not to have made a physician visit or telephone contact before admission (52% vs 41%). Only 26% of parents said that their childs admission was preventable, compared with 38% of PCPs and 43% of IAPs. The proportion of asthma hospitalizations that were assessed as preventable varied according to the source or combination of sources, from 15% for agreement among all 3 sources to 54% as identified by any 1 of the 3 sources. PCPs (83%) and IAPs (67%) significantly more often than parents (44%) cited parent/patient-related reasons for how hospitalizations could have been prevented, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (27%) and IAPs (26%) significantly more often than PCPs (11%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the childs condition, and better quality of care. Multivariate analyses revealed that an age ≥11 years and no physician contact before the hospitalization were associated with ∼2 times the odds of a preventable asthma hospitalization. Conclusions. The proportion of asthma hospitalizations assessed as preventable varies from 15% to 54%, depending on the source. Adolescents and families who fail to contact physicians before hospitalization are at greatest risk for preventable hospitalizations. Many pediatric asthma hospitalizations might be prevented if parents and children were better educated about the childs condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers.

Why Are Latinos the Most Uninsured Racial/Ethnic Group of US Children? A Community-Based Study of Risk Factors for and Consequences of Being an Uninsured Latino Child

Background. Lack of health insurance adversely affects children’s health. Eight million US children are uninsured, with Latinos being the racial/ethnic group at greatest risk for being uninsured. A randomized, controlled trial comparing the effectiveness of various public insurance strategies for insuring uninsured children has never been conducted. Objective. To evaluate whether case managers are more effective than traditional methods in insuring uninsured Latino children. Design. Randomized, controlled trial conducted from May 2002 to August 2004. Setting and Participants. A total of 275 uninsured Latino children and their parents were recruited from urban community sites in Boston. Intervention. Uninsured children were assigned randomly to an intervention group with trained case managers or a control group that received traditional Medicaid and State Children’s Health Insurance Program (SCHIP) outreach and enrollment. Case managers provided information on program eligibility, helped families complete insurance applications, acted as a family liaison with Medicaid/SCHIP, and assisted in maintaining coverage. Main Outcome Measures. Obtaining health insurance, coverage continuity, the time to obtain coverage, and parental satisfaction with the process of obtaining insurance for children were assessed. Subjects were contacted monthly for 1 year to monitor outcomes by a researcher blinded with respect to group assignment. Results. One hundred thirty-nine subjects were assigned randomly to the intervention group and 136 to the control group. Intervention group children were significantly more likely to obtain health insurance (96% vs 57%) and had ∼8 times the adjusted odds (odds ratio: 7.78; 95% confidence interval: 5.20–11.64) of obtaining insurance. Seventy-eight percent of intervention group children were insured continuously, compared with 30% of control group children. Intervention group children obtained insurance significantly faster (mean: 87.5 vs 134.8 days), and their parents were significantly more satisfied with the process of obtaining insurance. Conclusions. Community-based case managers are more effective than traditional Medicaid/SCHIP outreach and enrollment in insuring uninsured Latino children. Case management may be a useful mechanism to reduce the number of uninsured children, especially among high-risk populations.

Urban parents' knowledge and practices regarding managed care.

BACKGROUND. Latinos continue to be the most uninsured racial/ethnic group of US children, but not enough is known about the risk factors for and consequences of not being insured in Latino children. OBJECTIVE. The objective of this study was to identify the risk factors for and consequences of being uninsured in Latino children. METHODS. A cross-sectional survey was conducted of parents at urban, predominantly Latino community sites, including supermarkets, beauty salons, and laundromats. Parents were asked 76 questions on access and health insurance. RESULTS. Interviews were conducted of 1100 parents, 900 of whom were Latino. Uninsured Latino children were significantly more likely than insured Latino children to be older (mean age: 9 vs 7 years) and poor (89% vs 72%) and to have parents who are limited in English proficiency (86% vs 65%), non-US citizens (87% vs 64%), and both employed (35% vs 27%). Uninsured Latinos were significantly less likely than their insured counterparts to have a regular physician (84% vs 99%) and significantly more likely not to be brought in for needed medical care because of expense, lack of insurance, difficulty making appointments, inconvenient office hours, and cultural issues. In multivariable analyses, parents who are undocumented or documented immigrants, both parents working, the childs age, and the

Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters

4000 to

Access Barriers to Health Care for Latino Children

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The importance of language and culture in pediatric care: case studies from the Latino community.

15000 to

Keeping children out of hospitals: Parents' and physicians' perspectives on how pediatric hospitalizations for ambulatory care-sensitive conditions can be avoided

19999 family income quintiles were the only factors that were significantly associated with a childs being uninsured; neither Latino ethnicity nor any other of 6 variables were associated with being uninsured. Compared with insured Latino children, uninsured Latino children had 23 times the odds of having no regular physician and were significantly more likely not to be brought in for needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. CONCLUSIONS. After adjustment, parental noncitizenship, having 2 parents work, low family income, and older child age are associated with being an uninsured child, but Latino ethnicity is not. The higher prevalence of other risk factors seems to account for Latino childrens high risk for being uninsured. Uninsured Latino children are significantly more likely than insured Latino children to have no regular physician and not to get needed medical care because of expense, lack of health insurance, difficulty making appointments, and cultural barriers. These findings indicate specific high-risk populations that might benefit most from targeted Medicaid and State Child Health Insurance Program outreach and enrollment efforts.

An Evaluation of the Linguistic and Cultural Validity of the Spanish Language Version of the Children with Special Health Care Needs Screener

Background:Managed care is the dominant form of health insurance in the United States, covering millions of children. Little is known about whether inner-city parents adequately understand managed cares complex definitions and rules. Objective:The objective of this study was to examine managed care knowledge and practices among inner-city parents. Methods:We conducted a cross-sectional survey of parents at inner-city community sites in Boston, including supermarkets, hair salons, and laundromats. Participants were asked 74 questions on access, insurance, and managed care. Results:The 1100 participants were mostly poor, minority (82% Latino, 10% black) and covered by public health insurance. Although 55% of insured children were covered by managed care, 45% of the managed care-covered childrens parents were unaware of their childrens managed care coverage. When asked “What is managed care?,” 88% of parents did not know it was a type of insurance, and 94% did not identify a specific feature; Latino parents were significantly more likely to provide a wrong/do not know answer to this question, and there was no significant association with whether the child was covered by managed care. Latino parents and parents with children not covered by managed care were significantly more likely to provide a wrong/do not know answer for all 11 questions about specific features of managed care, but the proportion of parents with managed care-covered children who gave wrong/do not know answers for these 11 questions ranged from 41% to 84%. More than half of parents gave wrong/do not know answers to 10 of the 11 questions about specific managed care features, regardless of whether their child was covered by managed care. Most parents reported that if their child were covered by managed care, they would bring the child to the emergency department without prior approval for 4 minor childhood illnesses. For each of these illnesses, at least two thirds of parents said that they would bring their child in without prior approval, ranging from 72% of parents for a child with diarrhea to 90% for a child with a sprained ankle. Latino ethnicity (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.2–3.1), having a nonmanaged care-covered child (OR, 2.3; 95% CI, 1.5–3.7), and having a managed care-covered child but being unaware of the managed care coverage (OR, 2.9; 95% CI, 1.6–5.2) were associated with greater adjusted odds of incorrect/do not know parental definitions of managed care. Low family income and limited English proficiency were consistently associated with a significantly higher adjusted odds of wrong/do not know answers about specific managed care features. In multivariable analyses, Latino parents were significantly more likely to bring a managed care-covered child with a minor illness to the emergency department without prior approval. Conclusions:Regardless of whether their children have managed care coverage, most inner-city parents interviewed in this study do not know what managed care is, have insufficient knowledge of managed care rules and practices, and believe that prior approval for emergency department visits for mild childhood illnesses is unnecessary. These findings indicate that many urban parents may need better, more comprehensible information about managed care, particularly those who are poor, Latino, and have limited English proficiency.